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40 year old primi, BMI of 32,conceived twins with donor oocytes: how to make her journey safe?
Dr.Sameer Dikshit
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Fetal Medicine Consultant
Wadia Hospital S L Raheja Fortis
Hospital BSES MG Global
Hospital Boisar Fetal
Medicine Centre
Irla Nursing Home Belle Vue Nursing
Home Sanket Sonography
Centre
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Journey map…….
Pot holes…
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Scenic beauty…..
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Found pinned on the nursing station of a 5 star hospital in Mumbai…….
The doctors complain that the patients are more courteous to nurses than to them.
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40 year old
Height 162 cm, weight 84 kg, BMI
32
G1 P0
Donor oocytes
Twin Pregnancy
History…..
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Early Pregnancy Mid Pregnancy Late Pregnancy
First Trim ScreeningChorionicity
AbnormalitiesGrowth
Clinical Complications
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Early Pregnancy
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Early pregnancy scan
First Trimester Screening
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Age
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The recipient The donor
Age 40 years
Prior risk 1:83
Age 25
Prior risk 1:950-1001
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The background risk is the risk at the age of the “Donor” and NOT at the age of the “Recipient”
In this case, prior risk is NOT 1:83, but it is 1:1001
In case of donor oocytes..
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CHORIONICITY
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{ { T sign Lambda sign
MC Twin DC Twin
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DICHORIONIC TWINS
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The posterior risk in the two twins is different, and is determined by NT of individual twin
In Dichorionic Twins….
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MONOCHORIONIC
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The posterior risk of the two twins is the same, and it is calculated by taking a mean of the two NTs……..
In Monochorionic Twins…
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Let us add First Trimester Biochemistry……..
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Biochemistry in Twins is less accurate than in Singletons
Some advocate doing only NT
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The biochemistry risk is calculated taking into consideration, the age of the recipient into account
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SYSTEMATIC LABELING OF TWINS
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Comedy of errors
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Biometric measurements from serial
scans should be consistently allocated
to the same twin (Yo Yo phenomenon)
When doing invasive testing, the
“correct” twin has to be sampled
Necessary to communicate correctly
with the neonatologist, in case a twin
develops an abnormality postnatally
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Not applicable in
monochorionic twins or
dichorionic twins with fused
placenta
Placenta changes position
#1) Labeling of twins by position of placenta
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PNDT law
Not possible in same sex twins
Ultrasonographic identification of
fetal sex in early pregnancy may not
be conclusive#2) Labeling of twins by fetal sex
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The laterality of the gestational sac
relative to the cervix remains the same
because the base of the inter twin
membrane remains fixed
The rest of the inter twin membrane can
move about, allowing the twins to swap
position
#3) Labeling by position of base of inter twin membrane
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Up or Down
Right or Left
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Implicit that Twin 1 delivers before Twin 2
Fetuses designated as Twin 2 delivered first in 25% of cases of LSCS
Twin 1 (A) & Twin 2 (B)
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Fetus designated as Twin 2 delivered first in 5% of vaginal delivery
Perinatal switch
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Necessity is the mother of invention….
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VANISHING TWIN…….
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When live twins are detected prior to 7 weeks, only 71% resulted in birth of Twin neonates
This percentage increased to 84% when the gestational age reached 7-9 weeks
The chance of taking home, twin neonates is markedly reduced in the presence of threatened abortion, with only 63% take home baby rate
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There is significant relationship between CRL discrepancy at 7 + 0 to 9 + 0 weeks and the likelihood of single fetal demise
Discrepancy of 40% is associated with vanishing twin
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What happens to the survivor????
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IVF pregnancies with vanished co-twin had a higher rate of SGA than singletons from single gestation and the risk of SGA increased with increasing GA at the time of vanishing
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Use of biochemical markers in cases of vanishing twin is inaccurate and best avoided
The risk is calculated using ONLY NT
FIRST TRIMESTER SCREENING IN CASE OF VANISHING TWIN…..
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Incidence of hyperemesis is higher in twin pregnancy as compared to singleton pregnancy
After 11-14 weeks scan, rate of subsequent fetal loss before 24 weeks is 1% in singletons, 2% in DC twins and 10% in MC twins
Other possible complications…
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Early Pregnancy Mid Pregnancy
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Ultrasound scanning
Uterine Artery Doppler
Cervical length assessment
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DC - High risk pregnancy
MC DA - Very high risk pregnancy
MC MA – Extremely high risk pregnancy
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“Twin gestations should be followed routinely
with serial ultrasonographic follow-up for
growth at appropriate (currently, non evidence
based) intervals, irrespective of chorionicity. If
growth discordance is detected, surveillance
should be intensified.”
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Obesity
Difficulty in scanning the twin farther from the transducer
Double Movements
Difficulty in maneuvering of the transducer
Difficulties encountered in screening for malformations…
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A challenge to trace the anatomic parts to the respective Twin
Labeling of Twin
Constantly moving inter-twin membrane adds to confusion
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Twin to twin transfusion syndrome
TRAP (Twin Reversed Arterial Perfusion)
Selective IUGR
Death of one of the Twins
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Twin to Twin transfusion Syndrome
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Polyhydramnios and large bladder in recipient twin
Oligohydramnios and absent bladder in donor twin
“Stuck Twin” Folding of inter
Twin membrane
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Increased NT in one or both the Twins
Abnormal DV waveform in one or both the Twins
Inter-twin discrepancy in CRL is NOT predictive of TTTS
Inter-twin membrane folding
Early markers for TTTS..
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GROWTH RESTRICTION
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In singleton pregnancies the incidence of IUGR is 5%
In Dichorionic Twins it is 20%
In Monochorionic Twins it is 30%
In 2% of dichorionic and 8% of monochorionic Twins BOTH the twins have IUGR
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In singleton pregnancies, the reasons for IUGR are either abnormal placental function or genetic growth potential
In Dichorionic twins, IUGR is due to unequal genetic potential or disparity in placentation
In Monochorionic twins it is due to unequal splitting or due to unequal sharing of blood flow
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Selective IUGR and Growth Discordance
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Selective IUGR >10th centile + <10th
centile
Discordant Growth >20% difference
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Type I (Normal UA Doppler) Good Prognosis
Type II (absent or reversed end diastolic velocity flow) High incidence (50-60%) of perinatal mortality
Type III (intermittent ARDF or iARDF) due to Feto-fetal transfusion. Risk to BOTH IUGR (20%) and non IUGR (15%) twin
Prediction of adverse outcome- UA waveform of sIUGR Twin
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Death of one of the Twin
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There is risk of CNS damage to the
survivor
There is risk of perinatal mortality to
the survivor
Decision to deliver
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Vascular communication between the two twins
Surviving twin demonstrates severe multi organ damage
Either due to thromboembolic episodes or due to bleeding of survivor into the vasculature of the dead twin
Monochorionic Twins
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The risk to the survivor is significantly less
However, isolated cases of vascular communication have been reported in dichorionic twins too
Case reports of neurological damage in survivor of dichorionic twins
Dichorionic Twins
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sIUGR is more common before sIUFD
Fetal surveillance should not be less in dichorionic twins with sIUFD
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Would you still call them “weaker sex”….?????
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Cervical length
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Cervical lengths obtained between 16 and 31 weeks correlate with the risk of PT birth
Length <2.4 cm suggests high risk of PT birth
Could not come to any conclusion about treatment (cerclage, progesterone, tocolytics, rest)
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Treatment with micronized Progesterone did not prevent PT delivery in twins
Micronized Progesterone is NOT harmful to mother or twins
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Uterine Artery Doppler
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Uterine Artery doppler has an overall low sensitivity in predicting adverse obstetric outcome
Suggested that there are additional patho -mechanism causing PIH and IUGR in twins that is unrelated to uteroplacental insufficiency
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PI in twin pregnancies is consistently lower than singleton pregnancies
There is no difference in MC and DC twin Ut A characteristics
ABNORMAL Ut A findings in twins has a HIGHER positive predictive value
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The patients with ABNORMAL Ut A values represent those patients who are likely to have worst outcome
Hence screening for Ut A abnormalities should be carried out
The negative predictive value NORMAL Ut A findings is LOWER
Thus even NORMAL Ut A cases can have PIH/ IUGR
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Early Pregnancy Mid Pregnancy Late Pregnancy
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Late pregnancy complications in Twins
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Anemia-35.8% Hypertension-22.6% PPH-18.9%
Hyperemesis-7.5% Polyhydramnios- 5.7% Gestational Diabetes in 5.7%
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PIH IN TWINS
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The incidence of PIH in Twin pregnancy 18% compared to 5% in Singletons
The incidence of complications ( PT delivery, LSCS, Abruptio Placenta, PPH) was higher in PIH
The PIH is more likely to be severe
The adverse maternal outcome is also more common
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GESTATIONAL DIABETES
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The presence of GDM in Twin pregnancy was associated with higher risk of Hypertensive complications Prematurity RDS Macrosomia
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PT delivery & LBW
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Wish there were spell check in daily life too…..
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OPTIMUM TIMING FOR DELIVERY
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When the pregnancy is uncomplicated, the twins continue to grow and mature with the advancement of the gestational age
In the absence of maternal complications, it is advisable to deliver twins at 38 weeks
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Elective induction of labour v/s Expectant management
No statistically significant difference between two groups in the incidence of LSCS
No statistically significant difference between two groups in the incidence of adverse outcome
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ROUTE OF DELIVERY
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Both vertex twins Allow vaginal delivery
First breech/ Second vertex Elective LSCS
First vertex/ Second non vertex 84% LSCS
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ORDER OF BIRTH
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There was no association between birth order and risk of perinatal mortality before 36 weeks
Second twin born at term were at increased risk of perinatal death related to delivery
Vaginally delivered second twin had four fold increase in risk of death
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Controversies in Twins
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ANTENATAL CORTICOSTEROIDS
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What is the dose for Twins?
Should it be double to cover the two?
Do Twins mature earlier than Singletons?
If so, should you decrease the dose required?
In Triplets and higher order pregnancies, steroids are associated with intra uterine contractions and cervical changes….do these happen in Twins too?
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ELECTIVE LSCS
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Mono chorionic Twins to decrease hypoxic episodes?
Pre term Twins with first Vertex?
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NEONATAL COMPLICATIONS
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Low Birth weight
Prematurity
CNS complications
Cerebral Palsy
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The only person awake is probably the next speaker….
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Thank you……
